Mucor septic arthritis in a solid organ transplant patient with priorvoriconazole exposure

Gupta S, Fisk D

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Mucor septic arthritis in a solid organ transplant patient with priorvoriconazole exposure


• 48 y/o Caucasian male with Diabetes Mellitus- type 1and End stage renal disease, underwent a combined renal and pancreas transplant (9/ 2003). Tacrolimus and prednisone were prescribed for immunosuppression. • A transplant pancreatectomy was performed ten days after the transplant secondary to portal vein thrombosis with duodenal leak and Intra-abdominal abscess. The surgical pancreas specimen grew Candida glabrata on fungal culture. • Voriconazole 200 mg PO BID was prescribed from 9/8/03 to 10/26/03 (7 weeks). The treatment was interrupted from10/4 to 10/8 and he was given 400 mg IV BID on three days during that time period. • Three weeks after transplant, the patient sustained a traumatic fracture of his right femur which was treated with ORIF and intramedullary nailing. • 7.5 months post transplant, he presented with a right knee effusion, pretibial cellulitis and a pathologic tibial plateau fracture. A knee aspirate revealed 2000 WBC with 88 PMN. Culture of the aspirate Candida glabrata and Mucoraceae of the species Mucor There were no episodes of neutropenia prior to culturing mucor. • The patient was treated initially with caspofungin + amphotericin preparations. Open surgical debridement and reversal of immunosuppression was advised but did not happen. • The patient was readmitted two weeks later with worsening cellulitis over the tibia fracture site. • Surgical exploration and debridement revealed necrotizing fasciitis. Bone fragments and tissue damage extended into the joint space. Intraoperative culture again grew Mucoraceae of the species Mucor. A left foot lesion also grew Mucoraceae of the species Mucor. A right upper lobe nodular density seen on chest CT suggested pulmonary infection. • Shortly after obtaining the skin biopsy results, the patient died of cardiac arrest (on the 17th day of hospitalization). Discussion: • An extensive Medline search revealed one previously reported case of septic arthritis attributed to mucormycosis. The patient in that case had AIDS and the infection was caused by Cunninghamella bertholletiae. • We believe this is the first reported case of septic arthritis from mucormycosis in an HIV uninfected individual. • Several authors have recently reported zygomycosis in neutropenic hematopoietic stem cell transplant patients treated with prophylactic or empiric voriconazole. This solid organ transplant patient received voriconazole for treatment of resistant Candida infection, rather than prophylaxis. He subsequently developed disseminated zygomycosis in the absence of neutropenia. • This case associates zygomycosis with prior voriconazole exposure in the solid organ transplant population.

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15th Annual Focus on Fungal Infections